Transcript Intestinal Obstruction [ PPT ]

Intestinal Obstruction
Dr Bina Ravi
Associate Professor and Consultant
Department of Surgery
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Abdomen- Bowel sound
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Present- Mechanical obstruction
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Adynamic obstruction
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present-
(no gas under diaphragm)
Perforation
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(gas under diaphragm)
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Objectives
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Pathophysiology – dynamic, adynamic
Cardinal features – history, examination
Causes – small, large gut obstruction
Indications – contraindications for
conservative Mx
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Obstruction
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Dynamic – peristalsis, mechanical
obstruction
Adynamic- paralytic ileus, non
propulsive Mesenteric vascular
obstruction or, pseudo obstruction
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Dynamic Obstruction
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Pain, distention, vomiting, absolute
constipation
Two- small gut – high , low
Large gut
Acute , chronic, acute on chronic or,
sub-acute
Simple – intact vascularity
Strangulated – compromised
vascularity
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Intestinal obstruction:
Causes
Adhesion
Inflammatory
Carcinoma
Obstructed
hernia
Fecal
obstruction
Pseudoobstruc
tion
Misc
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Causes –Dynamic obstruction
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Intra-luminal –impaction, FB, Bezoars,
gallstones
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Intramural- strictures, malignancy
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Extra-luminal- bands/adhesions, hernia,
volvulus, intussusception
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Adynamic obstruction-causes
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Paralytic ileus
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Mesenteric vascular occlusion
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Pseudo obstruction
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Pathophysiology
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Proximal gut dilates- altered motility
Below the obstruction – normal motility,
immobile
Proximal – increased peristalsis, dilates,
reduced peristalsis, flaccid
Gas- bacteria. Aerobic/anaerobic, 90% N2
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Fluid- dig. Juices,
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Pathophysiology
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Dehydration and electrolyte imbalance
Reduced intake
Defective absorption
Vomiting
Sequestration in gut
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Strangulation
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Blood supply compromised
Venous return first affected, arterial
Hemorrhagic infarction
Translocation and systemic exposure
to microbes/ toxins
Morbidity/ mortality- age, extent,
Peripheral vascular failure
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Closed loop obstruction
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Strangulation
Distention
Necrosis
perforation
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Acute Intestinal Obstruction-CP
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Location, age of obstruction, pathology,
ischemia
Pain
Vomiting
Distension
Constipation
Dehydration, Hypokalemia, fever,
abdomen tenderness
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Pain – severe, colicky, umbilical, lower
abdomen
Increases with peristalsis, later reduces
Severe pain - strangulation
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Vomiting
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High obstruction- violent
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Low obstruction- slow onset
nausea/vomit
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Gradually digestive food changes to
feculent material
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Distension
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Greater if distal obstruction
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Visible peristalsis
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Peristalsis delayed in colonic obstruction
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Absent in Mesenteric vascular obstruction
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Constipation
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Absolute
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Relative
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Absent in – Richter’s hernia, gallstone,
MVO, Pelvic abscess, partial
obstruction
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Dehydration
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Vomiting, fluid sequestration
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Dry skin, poor venous filling, sunken
eyes, oliguria
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Raised blood urea, Hb, - secondary
polycythemia
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Hypokalemia
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K, amylase, LDH – strangulation, raised
TLC or, leucopenia
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Fever – indicates – ischemia,
perforation, inflammation
Hypothermia – septic shock
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Abdomen tenderness
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Localized – ischemia
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Peritonitis – infarction or, perforation
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Strangulation
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Diagnosis is clinical
Features of obstruction
Persistent pain, Shock, local tenderness
Non-responsive to conservative Mx
Hernia strangulation – tender, irreducible,
absent cough impulse, recent increase in
size
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Radiology
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Supine/ erect plain abdomen films
Small gut- central, transverse, no gascolon
Jejunum- valvulae connivantes
Ileum- featureless
Cecum- round gas in RIF
Large gut- haustral folds
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Supine
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Sigmoid volvulus
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Dilated, no haustral pattern
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Small gut- air and fluid levels
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More the fluid levels, more distal the
lesion
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Inv:
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Plain x ray- impacted foreign body
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Fluid levels – non obstructing
conditions – inflammatory bowel
disease, acute pancreatitis, abdominal
sepsis
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Treatment
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3 measures
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Intestinal drainage
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Fluid and electrolyte replacement
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Relief of obstruction
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Surgical Mx
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Mx of segment at the site of
obstruction
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The distended proximal bowel
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Underlying cause of obstruction
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Supportive
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NG tube drainage
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Na , water replacement
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Antibiotics
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Large gut
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Ca or diverticular disease
Contrast study – pseudo-obstruction
Caecal perforation- caecostomy,
ileostomy
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Adhesions/bands
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Commonest
Fibrin – adhesions-fibrinous, fibrous
Appendectomy , gynaecological op.
Bands- congenital, bacterial peritonitis,
greater omentum causing band
Mx- conservative – 72 hrs –lap
adhesiolysis
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Special obstructions
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Int. hernia – foramen of Winslow, hole in
the mesentery, hole in transverse
colon, defects in broad ligament, cong
diaphragmatic hernia, paraduodenal
fossae, intraperitoneal fossae
Mx- release the ring, reduction of
hernia
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Enteric strictures
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TB, Crohn’s, Ca, lymphomas,
stricturoplasty
Bolus obstruction – food, gall stone,
trichobezoars, phytobezoars,
stercoliths, worms
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Ac Intussusception
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Proximal gut enters distal gut
Adults – lead point, polyp, submucosal
lipoma, tumor,
Colo-colic – adults
Pathology- inner tube, outer tube,
returning of middle tube
Strangulating obstruction- ileoileal,
ileocaecal, ileocolic
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Clinical picture
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Severe attacks of pain – lasts few
minutes
Later - red currant jelly stool
Exam –between episodes-50-60%
sausage shaped lump – empty RIF –
Sign de Dance
P/R – blood stained finger
Later vomit, distension
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Radiology
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Plain film – absent caecal gas
Ba enema- claw sign
CT scan
Mx- Hydrostatic reduction with enema
Operative reduction
Recurrent – 5%- anchorage of ileum to
ascending colon
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Differential diagnosis
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Acute enterocolitis
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Henoch Schoenlein perpura
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Rectal prolapse
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Volvulus
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Axial rotation of bowel at its
mesentery
Congenital or secondary
Small intestine, caecum, sigmoidcommon
Small gut- spontaneous, vegetable
consumption – untwist
Caecal – clockwise- females- lap .
Untwist, resection if gangrene
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Sigmoid
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Anticlockwise
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Bands, overloaded colon, large
mesocolon, narrow pelvic mesocolic
attachment
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Treatment
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Flexible sigmoidoscopy/ rigid
Laparotomy- untwisting
Viable – fixing to retroperitoneum
Resection – Paul Mickulikz- gangrene
Sigmoid colectomy/ Hartmann’s
procedure later re-anastomosis
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Compound volvulus
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Rare, ile-osigmoid knotting
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Gangrene
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Laparotomy - Decompression,
resection and anastomosis
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Thanks
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